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Headache prevalence and its characterization amongst hospital workers in Enugu, South East Nigeria


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Headache prevalence and its characterization

amongst hospital workers in Enugu, South East


Ikenna Onwuekwe


, Tonia Onyeka


, Emmanuel Aguwa


, Birinus Ezeala-Adikaibe


, Oluchi Ekenze


and Elias Onuora



Background:Headaches are probably the commonest neurological complaint worldwide. Amongst workers it contributes significantly to loss of productive time and work efficiency. It is an important cause of disability and reduced quality of life. The prevalence and pattern amongst health workers in Africa has not been extensively studied.

Objective:This epidemiological sampling-based preliminary study examined the frequency and pattern of headache in a population of health workers of a tertiary hospital in Enugu, South East Nigeria.

Methods:Study participants, recruited by balloting, completed a self-administered questionnaire to screen for headache and its associations (defined as headache unrelated to fever and experienced within 6 months prior to the date the questionnaire was administered). Data analysis was by SPSS version 16. Ethical approval was obtained from the Hospital Ethical Review Committee.

Results:One hundred and thirty-three workers aged 18–70 years, were evaluated (males 53.4%, n = 71 and females 46.6%, n = 62). Headache was experienced by 88% of workers with primary headaches constituting more than 70% of cases. Females were more affected in both instances. Primary and secondary headaches occurred more in younger and older workers respectively and the association was significant (P <0.05). Headaches were not a significant cause of disability and loss of productivity.

Conclusion:Headaches are very prevalent in hospital workers in Enugu, Nigeria. In older workers screening for underlying causes is indicated. Disability, work absenteeism and loss of productive time are minimal despite the high headache prevalence.

Keywords:Headache, Pattern, Health workers, Nigeria


Headache is the commonest neurological disorder in the community with variable intensity, ranging from a trivial nuisance to a severe, disabling, acute or chronic disorder, and may impose a substantial burden on sufferers and on society [1,2]. It is one of the commonest reasons for visit-ing the neurology clinics worldwide [3-5], exertvisit-ing signifi-cant burden on its sufferers and impairing daily function especially when accompanied by other symptoms, hence

adversely affecting quality of life [6]. According to the World Health Organisation (WHO), 1.7–4% of the adult population of the world have headaches on 15 or more days every month [7] and a lifetime prevalence of more than 90% has been attributed to headache disorders in most populations of the world [8].

It is known that Africans have a higher threshold for pain and may not present to the clinic just for an‘ordinary headache’[9]. Local experiences show that patients suffer-ing from other chronic neurological disorders present very late to doctors and sometimes never do so [9]. Chronic headaches produce individual and societal burdens, the former referring to its effect on family, social and * Correspondence:doctortoniaonyeka@gmail.com


Department of Anaesthesia/Pain & Palliative Care Unit, University of Nigeria Teaching Hospital, Ituku-Ozalla, PMB 01129 Enugu, Nigeria

Full list of author information is available at the end of the article


recreational activities and the latter referring to effects on healthcare cost (direct costs) and work and function (in-direct costs), including absenteeism and reduced effective-ness [10].

There is limited data for headache prevalence in Africa. In 2004, the 1-year prevalence of headache from a door-to-door survey of rural south Tanzania was 23.1% (18.8% males and 26.4% females) [11]. Getahu and colleagues in Ethiopia found a 1-year prevalence rate of 73.2% [12]. A 1992 study from Ibadan, South West Nigeria, found the crude life-time prevalence for at least one episode of head-ache to be 51% [13].

In Nigeria, there is a paucity of data on the national prevalence and burden of chronic headaches [14] despite the fact that it is the commonest presenting neurological disorder in the authors’environment [1,3], and therefore the possibility that a big headache problem exists in Nigeria. There are also no known studies of the preva-lence and characterization of headache among Nigerian healthcare workers or healthcare workers in South East Nigeria hence the relevance of this study.

Aim of the study

The aim of this preliminary study was to determine the frequency and pattern of headaches among a population of healthcare workers in a tertiary health institution lo-cated in South East Nigeria.


This was an epidemiological sampling-based study (Figure 1) using a semi-structured questionnaire. The questionnaire was pre-tested in another health facility at Nsukka (a local government area similar to the study area) for content validity. English language was used to re-duce cross- cultural misinterpretations and wrong under-standing of terms.

The questionnaire was self- administered to all various cadres of health workers in medical unit of University of Nigeria Teaching Hospital, a tertiary health institution located in Enugu, South- East Nigeria, over a 3- month period from September – November 2013, selected by simple random method out of the various units in the hospital e.g. surgical, medical, laboratory, physiotherapy, nutrition, administrative, laundry, transport, security, and medical record. Within these are various cadres of hos-pital staff: physicians, nurses, pharmacists and cleaners. Out of a total of 141 only 133 gave consent and hence were studied, giving a response rate of 94.3%. To ascertain the overall prevalence of headache, subjects were asked if they have ever had a headache within the previous six months and to note any association. They were to rate the severity of headache based on a scale of mild, moderate and severe. The impact of these severe headaches on the daily activity and the number of days they occur in a month were recorded. The character of the pain, location,

Total no. of hospital employees = 2450 (450 medical doctors, 630 nurses, 50 pharmacists, 1320 laboratory and admin staff)

2309 not selected

141 selected using simple random method of the employment register

8 refused to give consent

133 (71 male, 62 females) gave informed consent and were studied

December 2013 to March 2014 - Manuscript writing December 2013 - data analysis


duration, and the total numbers of times in the 6 months preceding the date of administering the questionnaire were also noted.

Statistical Package for Social Sciences version 16 was used in statistical analysis. Comparison of multiplex groups was carried out with One Way ANOVA test. On the other hand comparison of two distinct groups was carried out with student t test. Chi-square test (and/or Fisher’s exact test) was used in analysis of categorical variables. The re-sults were revealed as mean ± SD. P value <0.05 was inter-preted as statistically meaningful. Ethical approval was obtained from the hospital ethics committee.


Of the 2,450 hospital employees (450 medical doctors, 630 nurses, 50 pharmacists, and 1320 laboratory and ad-ministrative staff ), 141 were selected using simple random method from the employment register and eventually only 133 health workers (71 males and 62 females) gave in-formed consent and were studied (response rate 94.3%). More of the respondents were males (53.4%) and most were within the 25 - 34 years age group (46.6%). Most of the workers had worked for only≤5 years (72.9%). Table 1 illustrates.

The prevalence of headache in the past 6 months was 88.0% (among males the prevalence was 87.3% while in

females it was 88.7%). There was no significant differ-ence observed between the sexes (p = 0.806). In both sexes, primary headaches were more prevalent (71.0% in males and 76.4% in females). There was also no signifi-cant difference in the prevalence of the primary head-aches among the sexes (p = 0.509). See Table 2.

Most respondents reported≤5 episodes of headache in the last 6 months (74.4%) and these were typically of short-lasting durations, <60 minutes (44.4%). There was no observed periodicity to the headaches in 57.3% of cases (see Table 3). Most of the headaches were not lo-cated in any particular part of the head or side-locked (71.7%); were described as mildly severe in 59.8% of cases while 88.0% of respondents did not suffer any sleep dis-ruption. The headaches were often not significantly disab-ling (73.4%) and in 93.2% of respondents did not lead to absenteeism or affect productivity at work (Table 4).

Stress (35.0%) and head trauma/illness/infection (18.8%) were the commonest predisposing conditions to the head-ache (Table 5). Refractive errors were present in 16.2% of respondents with headaches. In 25.6% there were head-ache prodromes and these included irritability (10.3%) and fatigue (5.1%). During the headaches, associated symp-toms occurred in 30.8% of respondents and these included nasal congestion, redness of eyes, sinusitis or allergies (26.5%) as depicted in Table 6. In most cases, there was no known family history of migraines or other chronic head-aches (Figure 2).

Management of headache was varied among respon-dents. In most cases (47.9%) no intervention was required. However in other instances, investigations (11.1%) and eye Table 1 Demographic distribution and work experience

of health workers

Variable Frequency Percent


Male 71 53.4

Female 62 46.6

Total 133 100.0

Age Group

15–24 13 9.8

25–34 62 46.6

35–44 36 27.1

45–54 15 11.3

55–64 6 4.5

65 and above 1 0.7

Total 133 100.0

Number of years worked

1–5 97 72.9

6–10 18 13.5

11–15 7 5.3

16–20 4 3.0

21–25 5 3.8

26–30 2 1.5

Total 133 100.0

Table 2 Prevalence of headache among the health workers

General prevalence of headache in the past 6 months

Variables Frequency Percent

Headache present 117 88.0

Headache absent 16 12.0

Sex prevalence of headache

Male (%) Female (%)

Headache present 62 (87.3) 55 (88.7)

Headache absent 9 (12.7) 7 (11.3)

Total 71 (100.0) 62 (100.0)


= 0.060; P value = 0.806

Type of headache

Primary 44 (71.0) 42 (76.4)

*Secondary 18 (29.0) 13 (23.6)

Total 62 (100.0) 55 (100.0)


= 0.436; P value = 0.509


checks (7.7%) were done. The over-the counter- available analgesic, paracetamol, (83.8%) was the commonest treat-ment received (Table 7).

The health workers’ ages did not significantly affect both the presence and treatment of headache (p = 0.483 and 0.293 respectively) but significantly affected the type of headache (p = 0.005) i.e. whether it was primary or secondary headache (Table 8). Years of working in the hospital did not significantly affect the prevalence of head-ache (P = 0.123), type of headhead-ache (P = 0.423) or treat-ment of the headaches (P = 0.535) as shown in Table 9. There was no correlation between the number of head-ache episodes and the number of years worked in the hos-pital [Pearson Correlation (r) = - 0.066] or age of the health worker [r = 0.001].


Headache is the commonest presenting neurological dis-order in most communities and clinical settings world-wide [2,12]. Studies from Nigeria, including Enugu, also support this [1,3,13]. The prevalence of headache in health care workers has been variously reported from Western countries [16,17] but there is a paucity of similar data from Nigeria and Africa. There was an inability to assess headaches as distinctly experienced in the various cadres of hospital workers and it was also not possible in this study to ascertain distinct headache entities and their roles. Other limitations of this study were its small sample size, the possibility of recall bias arising from patients’ an-swers to occurrences of headaches in the past 6 months, and use of a 3-point pain scale instead of the 10-point Visual Analogue Scale (VAS) which has greater scale re-finement and discrimination power. VAS has been noted to be a valid instrument for measurement of pain intensity in patients with headaches [18].

A prevalence of 88.0% was obtained for headaches amongst the hospital workers, with slightly higher rates Table 3 Characterization of the headaches

Variable/Characteristics Frequency

(N =117)


Number of episodes in past 6 months

1–5 87 74.4

6–10 25 21.4

11–15 3 2.6

16–20 2 1.6

Usual duration of headaches

Seconds 19 16.2

Minutes 52 44.4

Hours 36 30.9

Days 10 8.5

Usual time of day of the headache

Morning 18 15.4

Afternoon 15 12.8

Night 13 11.1

Continuous 4 3.4

No particular time 67 57.3

Is the headache becoming stronger, last longer or occur more frequent?

Yes 22 18.8

No 95 81.2

What is the commonest nature of the headache?

Throbbing/exploding 43 36.8

Sharp 4 3.4

Tightness 5 4.3

Dull 6 5.1

Aching 24 20.5

Pressure in head 32 27.3

Grinding 3 2.6

Table 4 Usual location and severity of the headache

Usual Location of headache Frequency Percent

Left side 3 2.6

Forehead 9 7.7

Around the head/ill-defined 11 9.4

Right side 2 1.7

Both Temples 2 1.7

Top of the head 1 0.9

Neck 2 1.7

Back of head 3 2.6

No particular side 84 71.7

Severity of headache

Mild 70 59.8

Moderate 45 38.5

severe 2 1.7

Is the headache strong enough to wake you from sleep?

Yes 14 12.0

No 103 88.0

Effect of headache on daily activities

No significant disability 16 13.7

Mild disability 86 73.4

Moderate 3 2.6

Severe disability 12 10.3

Headache–related work absenteeism or reduced productivity?

Yes 8 6.8


in females than males. Though the study periods vary, the figure compares favourably with the rate of 84.4% obtained amongst from health workers in the United States [16] but is significantly higher than the 54.7% and 27.1% prevalence rates obtained from Italian and Turkish health workers respectively [16,19]. A survey of headache in Ethiopian textile workers found a prevalence of 73% [12]. The headache prevalence of 88% for hospital workers in this study compares favourably with the 88.3% prevalence found in a study of medical students in the same locality [20]. The prevalence is also higher than the community prevalence rates of 51% and 23.1% seen in Ibadan, South West Nigeria and rural south Tanzania respectively [11,13]. It is possible that the different figures may reflect a combin-ation of environmental challenges, durcombin-ations of study and varied survey instruments used.

It is well noted that females tend to have higher rates for headache prevalence across cultures and continents [1,3,12,16,17,19] and while this seemed to be the case in our study, the difference was not statistically significant. Reasons adduced for the higher female prevalence in-clude the influence of oestrogens and progesterone on headaches after menarche and the greater propensity for females to seek medical attention for headaches [21].

Most of our subjects had probable primary headaches although no further attempts were made in this study to distinguish between the various different types (which

include the trigeminal associated cephalalgias (TACs), mi-graine and tension- type headaches). Headaches were of short duration (<60 minutes) and were not side –locked in most instances unlike the longer duration (>6 hours) migraine headaches noted in the Turkish study [19]. Mi-graine headache prevalence rate is uniformly low across much of Africa but was found to be significantly high in a cohort of textile mill workers in Ethiopia [12,22].

Stress, probably related to challenges in the work en-vironment, played the greatest role (35.0%) in this study and this reflected in the calming role attributed to relax-ation techniques utilized by the health workers (40.2%) to manage their headaches. Besides life and work stress, personality traits such as aggression, anger and type A behaviour are factors that may aggravate stress and are Table 5 Predisposing conditions to the headache

Factors preceding the headache Frequency (N =117) Percent

Accident, illness or infection 22 18.8

Odours 5 4.3

Fatigue 34 29.1

School 2 1.7

Hunger 17 14.5

Noise 4 3.4

Stress 41 35.0

Exercise 1 0.9

Family problem 2 1.7

Menstrual flow 2 1.7

Lack of sleep 8 6.8

Hot weather 2 1.7

None 49 41.9

Existing chronic medical conditions that may cause headache

Hypertension 10 8.5

Cervical spondylosis 3 2.6

Refractive errors 19 16.2

Diabetes mellitus 2 1.7

Sleep apnoea 1 0.9

None 97 82.9

Note that some respondents filled more than one option.

Table 6 Headache prodromes and other features associated with the headaches

Frequency (N =117)


Presence of warning signs before headache

Yes 30 25.6

No 87 74.4

Warning signs

Pallor 1 0.9

Mood swing 6 5.1

Irritability 12 10.3

Dizziness 3 2.6

Tired/sleepy 6 5.1

Rings around the eyes 1 0.9

Hyperactivity 1 0.9

Eye problems 2 1.7

None 104 88.9

Other symptoms associated with the headaches

Presence of other symptoms during the headaches

Yes 36 30.8

No 81 69.2

Nasal congestion, redness of eyes, sinusitis or allergies associated with the headache

31 26.5

Nausea. 2 1.7

Stomach pain 9 7.7

Vomiting 1 0.9

Confusion 3 2.6

Numbness in arms and legs 6 5.1

Diarrhoea 1 0.9

Dropping of the eyes 1 0.9

Fever 12 10.3


frequently found in headache patients but were not sought for in this study [22-24].

There was no significant association or correlation found between the prevalence of headaches and years of working experience in this study. Non-pharmacological treatment was suitable for almost half of respondents (47.9%) while the over-the –counter medicine, paraceta-mol, was the most utilised drug treatment. This finding is essentially similar to that of health workers with head-aches in the Unites States but contrasts with the use of NSAIDs in a Turkey study [17,19]. Despite working in a health facility, self-medication was commonly practised (35.9%) but this was even more significant among Turkish health workers (54.6%) [19].

The low rate of medical consultation for headache in hospital workers is of interest. In this study centre, head-ache ranks low among the disorders seen at both the Pain Clinic and Neurology Clinic accounting for only 2.7% of all neurological cases seen in the latter and 9thof the top 10 disorders encountered [3]. Some reasons adduced for the low rate of presentations to clinics for headaches as well as low rates of success in headache treatment amongst Africans include underdiagnoses or misdiagnoses due to lack of adequate knowledge by healthcare profes-sionals, headache sufferers being ignorant of effective prophylaxis and treatment, perception of headaches as a trivial problem, and great tolerance to pain [25-29]. Other reasons include poor healthcare facilities [30], low eco-nomic power [25], gender/child discrimination [28], and unavailability of effective medication [28,29]. The au-thors are of the opinion that African patients’ prefer-ence for/reliance on non-drug options (complementary and alternative medicine, CAM) [25,28,30] for pain re-lief may also be contributory.

Of important economic interest is the rarity of absen-teeism from work or loss of productive time as reported in this study. These factors are important because many Figure 2Family member with history of headaches, migraines, sick headaches, motion sickness or had trouble taking birth control pills because of headaches.

Table 7 Management received for the last headache episode

Management actions Frequency (N =117) Percent

Headache was managed by–

Health worker 19 16.2

Self 42 35.9

No treatment received 56 47.9

A. Investigations done

Laboratory 13 11.1

Eye check 9 7.7

B. Treatment received

Anti-malaria 7 6.0

Ergotamine 1 0.9

Food 1 0.9

Ibuprofen 5 4.3

Other NSAIDs* 2 1.7

Paracetamol 98 83.8

Tramadol (narcotic analgesic) 1 0.9

Eye glasses were prescribed 16 13.7

Relaxation 1 0.9

Other actions that relieve the headaches

Cold compress 13 11.1

Eating 20 17.1

Massage 3 2.6

Moving around 3 2.6

Relaxation 47 40.2

Sleep 31 26.5

Vomiting 1 0.9

Others 1 0.9


headache sufferers are at the peak of their work-productive life [26]. Employers may lose an average of 12 days per year because of an employee headache syndrome [27]. The au-thors relate reason for the rarity of work absenteeism and loss of productive time to the majority of headaches being of a mild nature with low disabling rates. A similar negli-gible rate of absenteeism was the outcome among Italian health workers with headache [16].


This preliminary study has revealed headaches to be common in this community of healthcare workers. How-ever, the seemingly low effect of headache on health workers productivity in this study, despite its high preva-lence rate and contrary to views [28] from other African studies, is of notable relief in a developing economy like Nigeria where health indicators are unimpressive and medical services still face huge challenges. In addition, presentation to Pain or Neurology clinic for headache dis-orders by respondents in this study has been shown to be low, demonstrating the need for increased and continuous health awareness on headache disorders as well as en-hanced occupational health services in Nigerian hospitals. By the findings of this work, the authors encourage more robust studies on headache disorders among healthcare workers in African countries with a view to informing better practice decisions and reducing the global head-ache burden.

Competing interest

The authors declare that they have no competing interests.


TO and IO conceptualised the study; TO, IO, EA, BE, OE and EO designed the questionnaire and collected data; TO, EA and IO analysed the data; all authors participated in drafting the manuscript; all authors read and approved the final manuscript.


The authors are grateful to Dr. Ada Shirley for her co-operation with data collection.


This study was not supported by a grant.

Table 8 Age group and management of headache

Age group in years

Variables 15 -24 25 - 34 35 - 44 45 - 54 55 - 64 ≤65

Presence of headache

Yes 12(92.3) 53(85.5) 34(94.4) 13(86.7) 4(66.7) 1(100.0)

No 1(7.7) 9(14.5) 2(5.6) 2(23.3) 2(33.3) 0(0.0)

Total 13 (100.0) 62(100.0) 36(100.0) 15(100.0) 6(100.0) 1(100.0)

Likelihood-ratioχ2= 4.480; P value = 0.483 Type of headache

Primary 7(58.3) 45(84.9) 27(79.4) 6(46.2) 1(33.3) 0(0.0)

Secondary 5(41.7) 8(15.1) 7(20.6) 7(53.8) 3(66.7) 1(100.0)

Total 12(100.0) 53(100.0) 34(100.0) 13(100.0) 4(100.0) 1(100.0)

Likelihood-ratioχ2= 16.995; P value = 0.005 (significant) Treatment of headache

Other health worker 10(83.3) 33(62.3) 18(52.9) 10(76.9) 3(66.7) 1(100.0)

Self 2(16.7) 20(37.7) 16(47.1) 3(23.1) 1(33.3) 0(0.0)

Total 12(100.0) 53(100.0) 34(100.0) 13(100.0) 4(100.0) 1(100.0)

Likelihood-ratioχ2= 6.135; P value = 0.293

Table 9 Number of years worked in the hospital and management of headache

Number of years worked in the hospital

Variables 1 - 10 11 - 20 21 - 30

Presence of headache

Yes 101(87.8) 11(100.0) 5(71.4)

No 14(12.2) 0(0.0) 2(28.6)

Total 115(100.0) 11(100.0) 7(100.0)

Likelihood-ratioχ2= 4.199; P value =0.123 Type of headache

Primary 75(65.2) 8(72.7) 3(42.9)

Secondary 40(34.8) 3(27.3) 4(57.1)

Total 115(100.0) 11(100.0) 7(100.0)

Likelihood-ratioχ2= 1.719; P value = 0.423 Treatment of headache

Other health worker 78(67.8) 7(63.6) 6(85.7)

Self 37(32.2) 4(36.4) 1(14.3)

Total 115(100.0) 11(100.0) 7(100.0)


Author details


Neurology Unit, Department of Medicine, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria.2Department of Anaesthesia/Pain & Palliative Care Unit, University of Nigeria Teaching Hospital, Ituku-Ozalla, PMB 01129 Enugu, Nigeria.3Department of Community Medicine, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria.4Department of Anaesthesia, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria.

Received: 4 August 2014 Accepted: 11 November 2014 Published: 25 November 2014


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Cite this article as:Onwuekweet al.:Headache prevalence and its characterization amongst hospital workers in Enugu, South East Nigeria.

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Figure 1 Flow chart of research activities.
Table 1 Demographic distribution and work experienceof health workers
Table 4 Usual location and severity of the headache
Table 5 Predisposing conditions to the headache


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